Access to Healthcare as a Driver of Place-Based Inequality in Mid-Life Mortality: Evidence from Movers in Medicaid

获得医疗保健是中年死亡率地区不平等的一个驱动因素：来自医疗补助推动者的证据

• 批准号: 10583235
• 负责人: Jacob Witt Samuel Wallace
• 金额: $ 49.94万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-09-15 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10583235
• 关键词: Address; Adoption; Adult; American; Area; California; Caring; Characteristics; Climate; Clinical; Communities; Complex; Consensus; Country; County; Data Set; Destinations; Disparity; Economics; Effectiveness; Ethnic Origin; Evidence based treatment; Family; Gender; Geography; Goals; Grant; Health; Health Insurance; Health Services; Health Services Accessibility; Healthcare; Improve Access; Individual; Inequality; Inequity; Institution; Insurance Coverage; Interdisciplinary Health Team; Intervention; Life Expectancy; Literature; Living Costs; Longevity; Low Income Population; Low income; Medicaid; Medicare; Mental Health Services; Mental disorders; Methodology; National Institute of Mental Health; Neighborhoods; Outcome; Persons; Pharmaceutical Preparations; Policies; Population; Positioning Attribute; Public Health; Public Policy; Quasi-experiment; Race; Research; Research Design; Research Personnel; Role; Shapes; Social Gradients; Sorting; Source; Substance Use Disorder; Suicide; System; Time; United States; United States National Institutes of Health; Vermont; Woman; alcohol-related death; behavioral health; design; evidence base; geographic difference; health care availability; health care delivery; health care disparity; health care service; health care service utilization; health difference; health disparity; health disparity populations; health equity; health inequalities; improved; innovation; men; middle age; migration; mortality; novel; policy implication; population health; programs; sociodemographic group; sociodemographics

PROJECT SUMMARY It is well-documented that where you reside in America shapes when you die, and this has been shown to be particularly true among low-income Americans. These place-based inequalities in health have grown over time in the United States, driven by increased mid-life mortality due to drug- and alcohol-related deaths and suicides. While the drivers of this rise in mid-life mortality are complex and multifactorial, there is broad consensus that the adoption of evidence-based treatments for substance use disorder and mental illness has the potential to improve health and save lives. Despite their effectiveness, behavioral health services are generally thought to be underused, with very limited access to these services in some regions of the country. We study the drivers of place-based inequities in the Medicaid program, the primary source of insurance coverage and payer of behavioral health services for low-income populations. This application seeks to understand whether and to what extent place-based inequalities in mid-life mortality — and their gradients by gender and race/ethnicity — are driven by the causal effects of place on access to evidence-based behavioral healthcare treatment by studying the low-income population on Medicaid. Because families sort into areas based on a wide range of factors — e.g., economic opportunity, amenities, cost-of-living, etc. — if people predisposed to poor (or good) health outcomes tend to cluster in particular localities then observed health differences between areas may reflect this non-random sorting (or “selection”) rather than the causal effects of place. To address this challenge, we use a quasi-experimental movers research design that follows otherwise similar Medicaid enrollees residing in the same place that move to different destinations. Subsequent differences in their healthcare utilization and health can be attributed to place effects if movers are observed for a period of time before the move to adjust for baseline outcomes. Second, to better under social gradients we stratify by sociodemographic characteristics and recover the effects of places for distinct groups —comparing differences in the impacts of a place on different groups reveals whether it tends to narrow or widen inequalities. Finally, we examine whether place-based effects correlated with immutable characteristics of areas (e.g., climate) or features that are more readily amenable to policy intervention (e.g., the healthcare delivery system). We make an original contribution, by advancing the understanding of the relationship between “place” and health for low-income populations, with a focus on understanding the role of differential access to high-quality, behavioral healthcare services.

项目摘要 有充分记录的是，您死亡时居住在美国的地方，这已被证明是 在低收入美国人中尤其如此。这些基于地方的健康不平等会随着时间的流逝而增长 在美国，由于与毒品和酒精有关的死亡和自杀导致的中年死亡率增加。 尽管这种中期死亡率的驱动因素是复杂而多因素的，但仍有广泛的共识是 采用基于证据的药物使用障碍和精神疾病的治疗有可能 改善健康并挽救生命。尽管它们有效，但通常认为行为健康服务 在该国某些地区获得这些服务的访问非常有限。我们研究驱动程序 医疗补助计划中的基于地点的不平等，保险范围的主要来源和付款人 低收入人群的行为卫生服务。本应用程序试图了解是否以及 在中年死亡率中基于地点的不平等及其性别和种族/种族的梯度是 受位置对通过研究获得基于证据的行为医疗治疗的因果影响的驱动 医疗补助的低收入人口。因为家庭基于广泛的因素将其分为区域 - 例如，如果人们易于贫穷（或良好）健康，经济机会，便利设施，生活成本等 结果倾向于聚集在特定地区，然后观察到区域之间的健康差异可能反映了这一点 非随机分类（或“选择”），而不是地方的因果效应。为了应对这一挑战，我们使用 准实验推动者研究设计，否则居住在 移至不同目的地的地方。随后的医疗保健利用和健康差异 如果在移动调整之前观察到一段时间内移动，则可以归因于位置效果 基线结果。第二，在社会梯度下更好地，我们按社会人口统计学特征和 恢复对不同群体的位置的影响 - 将地方对不同的影响的影响差异 小组揭示它往往趋于狭窄还是宽阔。最后，我们检查了基于地点的效果是否 与不变的区域特征（例如攀岩）或更容易适应的特征相关 政策干预（例如，医疗保健提供系统）。我们通过推进 了解低收入人群的“地方”与健康之间的关系，重点 了解差异访问获得高质量，行为医疗保健服务的作用。